Conventional and Unconventional Medicine:
Can They Be Integrated?

Archives of Internal Medicine 1998 (Nov 9); 158 (20): 2215-2224

James E. Dalen, MD, MPH

THIS ISSUE of the ARCHIVES, as well as the 8 other specialty journals
and JAMA, is dedicated to complementary, alternative, and integrated medicine.
Complementary and alternative medicine are also termed unconventional medical therapy, which Eisenberg et al1
have defined as "medical interventions that are not taught extensively at
US medical schools or generally provided at US hospitals." Conventional medicine can then be defined as medical interventions
that are taught extensively at US medical schools and generally provided at
US hospitals.

Eisenberg and colleagues1 noted that
34% (60 million) of the general public in the United States reported using
1 or more forms of unconventional medicine in 1990. The most frequently used
unconventional modalities are various forms of relaxation therapy,2, 3 chiropractic,4
acupuncture,5, 6 massage therapy,7 and herbal/mineral/vitamin supplements.8-10
The number of visits to unconventional providers in the United States in 1990
was greater than the number of visits to all primary care physicians. The
total expenditures for unconventional therapy in 1990 amounted to $13.7 billion,
$10.3 billion of which was paid out-of-pocket. In the vast majority of cases
(89%), these visits to unconventional providers were not prescribed by a physician,
and 72% of the patients did not discuss these visits with their physicians.1

What is the reason for this incredible disconnect? Patients seek unconventional
medical care because they believe that it will, or does, help them. Why are
conventional physicians reluctant to refer patients to unconventional therapy?

Some of the terms that are frequently used to differentiate conventional
therapy from unconventional therapy are listed
below:

Perhaps the most compelling (and most inflammatory) label is that conventional
medicine is scientific and that unconventional is unscientific. It is a fact
that many conventional physicians (ie, graduates of US medical schools) state
that they do not refer patients to practitioners of unconventional medicine
because their methods are not scientific and their qualifications are uncertain.

The definition of what is scientific in medicine obviously varies over
time. I am sure that the leading conventional US physician of the 18th Century,
Benjamin Rush, and his colleagues were convinced that bloodletting and purging
were examples of scientific medicine. (I am not sure that George Washington
agreed!)

At the present time in American medicine, scientific medicine is that
which is judged to be evidence based. What is evidence-based medicine? In
the 1990s, it means that a therapy has been shown to improve well-defined
patient outcomes by well-designed, appropriately powered, randomized, controlled
clinical trials. All drugs that have been approved by the Food and Drug Administration
since the 1960s have met this standard. Conversely, many therapies introduced
before the 1960s do not meet our current definition of scientific, or evidence-based,
medicine.

Let us look at our current therapies for cardiovascular diseases. Cardiovascular
diseases and their outcomesmyocardial infarction, stroke, pulmonary
embolism, and deathare readily and reliably documented. Many of them
are treated with antithrombotic agents. Three of the major antithrombotic
agents that are prescribed by Western-trained physicians for millions of patients
every day were introduced prior to the era of the randomized clinical trial:
warfarin,11 aspirin,12
and heparin.13

What is the scientific evidence that these 3 drugs prevent myocardial
infarction, stroke, pulmonary embolism, or death? The American College of
Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy was
convened in 1985 to examine the available evidence and to make recommendations
for antithrombotic therapy. Their recommendations were graded A, B, or C according
to the rules of evidence described by Sackett14
(Table 1). Grade A recommendations,
based on the results of appropriately designed randomized clinical trials,
were considered to be evidence based.

After the available evidence on the efficacy and safety of these agents
was examined, it was found that only 24% of the 1986 recommendations were
based on grade A evidence; ie, only 24% of their recommendations were evidence
based as currently defined.15 Of note, 55%
of their recommendations were based on uncontrolled clinical observations
and therefore were grade C (most evidence for the efficacy of unconventional
therapies is grade C at best.) The ACCP consensus conferences helped to stimulate
a flurry of appropriately designed randomized clinical trials on antithrombotic
therapy from 1986 to 1998. The fifth ACCP Consensus Conference on Antithrombotic
Therapy, which took place in 1998,16 reflects
the impact of these trials: 44% of the 1998 recommendations are grade A, ie,
evidenced based. Nearly all the recommendations for therapies recently approved
by the Food and Drug Administration (thrombolytics, ticoplidine, platelet
glycoprotein II/IIIA antagonists) are grade A. However, many of the recommendations
for the older, widely prescribed drugs (warfarin, heparin, and aspirin) remain
grade C (not evidence based). If these therapies (eg, warfarin to prevent
stroke in patients with mitral stenosis complicated by atrial fibrillation)
are not evidence based as currently defined, are they unconventional therapies?

The reason that most unconventional therapies are not evidence based
as currently defined is that most of them were introduced long before (in
some cases centuries before) the advent of the randomized controlled clinical
trial. It is also true that most therapies considered to be unconventional
arose outside modern mainstream Western medicine.

Further examples of nonevidence-based therapies that are or have
been widely prescribed by Western physicians for patients with cardiovascular
disease are evident in the use of various procedures (which are less tightly
regulated than drugs.) Coronary artery bypass grafts were first performed
in 1964.17 The efficacy of this procedure based
on the early reports seemed self-evident. Therefore, the procedure was performed
in hundreds of thousands of patients with coronary artery disease, even though
its efficacy was not confirmed by randomized clinical trials until 1977.18 Percutaneous transluminal coronary angioplasty followed
a similar course. It was described in 1979,19
and, as in the case of coronary artery bypass grafts, was then performed in
hundreds of thousands of patients prior to the first randomized clinical trial
demonstrating efficacy in 1992.20 The procedure
of bedside pulmonary artery catheterization was described in 1970,21 and it has been performed in millions of patients
without scientific evidence that it improves patient outcomes.22
In fact, some studies have suggested that it may in fact cause harm to some
patients.23

It is clear that many of the therapies prescribed by Western-trained
physicians are not evidence based as currently defined. Does this mean that
they should be defined as unconventional therapies? I believe that the reason
that they are not considered to be unconventional therapies is that they were
introduced from the mainstream of Western medicine. Does this mean that they
should be abandoned? I think not. It means that they should be subjected to
appropriately designed randomized clinical trials to establish their efficacy
and safety.

Table 2 compares various
characteristics of conventional medical therapies with those of unconventional
therapies. The fact that unconventional therapies are infrequently prescribed
by graduates of US medical schools is not surprising, since unconventional
therapy is infrequently taught in US medical schools. As noted above, many,
but not all, conventional therapies are evidence based, whereas very few unconventional
therapies are evidence based. One of the reasons that most unconventional
modalities are not evidence based is that the majority of them were introduced
prior to the 20th Century; therefore, they were not subjected to randomized
clinical trials.

In my opinion, the principal distinguishing characteristic of unconventional
and conventional medicine therapies is their source of introduction. Conventional
therapies are introduced by mainstream Western physicians and scientists,
whereas most unconventional modalities are introduced by "outsiders." I agree
with Goodwin and Tangum,24 who, in this issue
of the ARCHIVES, conclude that American academic medicine has a bias against
outsiders who make therapeutic suggestions, especially when they take their
message directly to the public.

Promising unconventional therapies must be subjected to the same level
of scientific scrutiny that we now require for drug therapies introduced by
"mainstream" medicine. As physicians whose job description requires us to
help people, we cannot reject "out-of-hand" any proposed therapies just because
they did not originate in modern mainstream medicine. We cannot wear blinders!

This is the challenge for integrative medicine! The leaders of integrative
medicine must sort through the myriad of proposed unconventional therapies
to determine which should be subjected to appropriately designed clinical
trials. The best candidates for study may be those that meet at least grade
C levels of evidence, as outlined by Sackett in Table 1.

If a therapy that arose from outside the mainstream of modern Western
medicine can pass the same level of scrutiny that we expect of conventional
therapies, it should be integrated into mainstream medicine and added to the
therapeutic armamentarium of the well-trained, conventional physician. We
can do no less for our patients!

We could learn from the Navajo, as described by Kim and Kwok25 in this issue of the ARCHIVES. The Navajo have integrated unconventional Western medicine, which is provided by the
Indian Health Service, into their centuries-old conventional health care, which is provided by native healers.